RAJIV GANDHI UNIVERSITY OF HELATH SCIENCE
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THECANDIDATE
AND ADDRESS / Ms. JESMI SKARIA
1ST YEAR M.Sc NURSING
THE OXFORD COLLEGE OF NURSING,
1ST PHASE J.P.NAGAR,
BANGALORE – 78
2 / NAME OF THE
INSTITUTION
AND ADDRESS / THE OXFORD COLLEGE OF NURSING,
1ST PHASE J.P.NAGAR,
BANGALORE – 78
3 / COURSE
OF STUDY
AND SUBJECT / DEGREE OF MASTER OF NURSING.
OBSTETRICAL AND
GYNAECOLOGICAL NURSING.
4 / DATE OF
ADMISSION
TO COURSE
/ 29.05.20085 / TITLE OF THE
TOPIC / “EFFECTIVENESS OF SELF
INSTRUCTIONAL MODULE
ON RH-ISOIMMUNIZATION.”
6. INTRODUCTION:
“Knowledge is the key to healthier life. And education is powerful medicine” K Park.
The average woman who enters pregnancy in good health achieves a successful pregnancy and birth without complications. In a few women, however, for reasons that usually are unclear, unexpected deviations or complications from the course of normal pregnancy occur. When this happens, it can place a severe burden on a woman and her family. All families benefit from the support and skill of a professional nurse who helps them work through the tasks of pregnancy and prepare to become new parents. A complication that results in loss of the fetus can be devastating. Sometimes the complication of pregnancy puts the women’s life in danger and difficult treatment choices must be made, such as the risk to the fetus if she is delivered early.1
There are several situations that can cause problems for the fetus related to blood incompatibilities between the woman’s blood and the fetus blood. Normally the blood streams never meet. But occasionally some type of trauma occurs that allows intermingling of the two blood streams. This situation is more likely to occur during invasive procedures such as amniocentesis or active labor, after spontaneous abortion, or when the placenta separates at birth.1
Approximately 15% of whites and 10% of African Americans in the US are missing the Rh-D factor in their blood or have Rh-negative blood type.2 A blood incompatibility disorder where the mother’s blood type is not cognitive with the fetus. This compatibility results in antibodies from the mother’s blood destroying the baby’s red blood cells when they come into contact during pregnancy and after birth. Without treatment the condition can cause serious complications and even death. The two different blood types involved are Rh-negative or Rh-positive. The mother does not develop antibodies to the baby’s blood until after the delivery. So the first baby is not affected but any subsequent babies can be affected during the pregnancy or after the birth.3
6.1 NEED FOR THE STUDY:
Rh-isoimmunization is still related with a high perinatal mortality and morbidity. The main problem is inadequate prevention. This is supported by a study conducted in tertiary referral center in Croatia among 23 pregnant women with Rh-isoimmunization, to assess the current problem of Rh-isoimmunization. Retrospective case analysis included women with Rh-isoimmunization `treated in the department of obstetrics and gynecology from January 1997 to January 2003. Results showed that perinatal mortality was 13% and the median gestational age at delivery was 34 weeks (range 31-40). In all, there were 31 fetal exchange transfusions after delivery performed in 14/20 newborns.4
Most causes of Rh-isoimmunization can be prevented by the administration of anti-D immune globulin (anti-D) to Rh-D negative blood type mothers who have a body with an Rh-D positive blood type. Following the birth, the infant’s Rh-D type is confirmed from cord blood testing. In addition, a kleihauer test is carried out which are estimates the number of fetal cells in a sample of maternal blood obtained after the birth.5
Midwives play an important preventive role in administering anti-D intramuscularly to the mother within 72 hours of birth or any abortion; the anti-D immunoglobulin is injected into the deltoid muscle from which absorption is optimal. This destroys any fetal cells in the mother’s blood before her immune system produces antibodies, and thus prevents Rh-sensitization. It is vital that an adequate amount of anti-D is given if Rh-isoimmunization is to be avoided in future pregnancies. A second dose is needed if the kleihauer test indicates that higher levels of fetal cells are present in maternal blood (above 50 fetal cells/50 low power fields). In such cases a further blood test is also ordered to ensure that an adequate amount of anti-D has been given.5
Staff development programme is the key to quality nursing care that helps to facilitate the competence of nurses in practice. Continuing education provides means by which nurses can update their knowledge and practice with current developments and maintain their competence and meet the standard of nursing practice. This is supported by a descriptive study conducted on random samples of 100 nurses, 102 physicians and 14 pharmacists regarding hazards of medications where the nurses proved to be the least knowledgeable. The study recommended that continued education could improve of the nurses regarding drugs.6
Hence, by the above statements, previous clinical experiences and personal interest on the topic, the investigator rightly justify the need for assessing the effectiveness of self instructional module on Rh-isoimmunization among staff nurses with a view to update and improve their knowledge.
6.2 RIEVIEW OF LITERATURE:
Review of literature for the present study has been organized under the following headings.
6.2.1 STUDIES RELATED TO RH-ISOIMMUNIZATION.
6.2.2 STUDIES RELATED TO THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE.
6.2.1 STUDIES RELATED TO RH-ISOIMMUNIZATION:
The frequency of isoimmunization increased with increasing number of pregnancies (4.9% for second pregnancies to 45.4% for fifth pregnancies). This study was carried out in Ramadi, Iraq over the period 1993 to 1997. Of 487 Rh-negative mothers tested and followed up, 172 were primigravida, 1.7% of who was Rh-isoimmunized. The results showed that initial screening of the pregnant women admitted to the clinic for Rh-antibodies revealed that none of the patients in the primigravida group was positive in the first trimester. After delivery, screening showed that 3 out of the 172 were positive (1.7%). After each subsequent pregnancy, the percentage of mothers with Rh-isoimmunization increased gradually from 4.9% in the second pregnancy to 45.4% in the fifth pregnancy, with a total of 49 positives out of 315 (average 15.6%).7
Antenatal prophylaxis with Rh-immunoglobulin will be necessary if the incidence of Rh-isoimmunization is to be reduced to its lowest possible level. A study conducted on 3533 Rh-negative women who began a pregnancy without detectable Rh-antibodies. The findings showed that the Rh-isoimmunization during pregnancy or within 3 days after delivery is the most important cause of residual Rh-isoimmunization. And in 1357 Rh-negative pregnant women who were delivered Rh-positive babies, was effective in preventing the development of Rh-isoimmunization during pregnancy or with in 3 days after delivery.8
With the available knowledge and resources, all health care professionals can further decrease the current rate of Rh- isoimmunization with closer adherence to proposed management guidelines. A study was conducted on current perspectives and treatment of Rh-isoimmunization. The study revealed that the management options for Rh-D compromised gestations continue to evolve almost as quickly as technological advances are made. Multiple areas of research in this field have surfaced, and nurses can become valuable members of these research teams. 9
Anti-D given within 72 hours after childbirth, reduces the risk of Rh-isoimmunization in Rh-negative women who have given birth to a Rh-positive infant. The study conducted on department of obstetrics and gynecology, department of medical genetics and fetal medicine, university hospital, Olomouc, ministry of health, Czech Republic among Rh-negative women who had given birth to a Rh-positive infant. The findings showed that the risk of Rh-isoimmunizaiton during or immediately after a first pregnancy is about 1%.And administration of 100 microgram (500IU) anti D to women in their first pregnancy can reduce this risk to about 0.2% without, to date, any adverse effects.10
6.2.2 STUDIES RELATED TO EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE:
Self-instructional module is an effective learning tool to enhance the knowledge. It is a learning resource that preplanned with prespecified objectives which includes the teaching learning materials. It is one of the most effective teaching strategies. This is a supported by several studies conducted by several people on effectiveness of self-instructional module
A study was conducted among staff nurses in selected hospitals, Bangalore on selected obstetric drugs to assess the effectiveness of self-instructional module. The results showed that the mean post-test knowledge score 40.14 (73%) was significantly higher than the mean pre-test knowledge score 28 (52%) with ‘t’ value 16.7 at < 0.01 level of significance and the findings reveals that the self instructional module is an effective tool in increasing the knowledge.11
A study was conducted among staff nurses in selected hospitals, Bangalore knowledge regarding active management of third stage of labor to assess the effectiveness of self-instructional module. The results showed that the mean post-test knowledge score 37.73 (99.28%) was significantly higher than the mean pre-test knowledge score 26.23 (69.02%) with‘t’ value 18.85 at < 0.01 level of significance.12
Impact of self-instructional module on management of patients having chest tube drainage was assessed among 100 staff nurses working in Nehru Hospital, Chandigar showed that in pre-test, subjects had poor knowledge related to clamping of chest tubes during transportation (35%)/, clamping during leak (28%) and about indications for chest tube removal (19%). After introduction of self-instructional module, knowledge of subjects further increased to 75%, 65% and 74% respectively in this area.13
STATEMENT OF THE PROBLEM:
Effectiveness of self-instructional module on Rh-isoimmunization among staff nurses working in maternity units of selected hospitals, Bangalore.
6.3 OBJECTIVES OF THE STUDY:
1. To assess the knowledge of staff nurses on Rh-isoimmunization in terms of pre-test knowledge scores.
2. To develop self-instructional module on Rh-isoimmunization.
3. To assess the post intervention knowledge of staff nurses by post-test knowledge scores.
4. To assess the effectiveness of self-instructional module by comparing pre and post-test scores.
5. To determine the association between the knowledge scores and selected variables
6.4 RESEARCH HYPOTHESIS:
H1 - The mean post-test knowledge scores of staff nurses will be significantly higher than mean pre-test knowledge scores.
H2 – There will be significant association between pre-test knowledge scores and selected variables.
VARIABLES UNDER STUDY:
Independent variable: Self-instructional module on Rh-isoimmunization.
Dependent variable: Knowledge scores of staff nurses on Rh-isoimmunization.
6.5 OPERATIONAL DEFINITIONS:
EFFECTIVENESS: In this study, it refers to the extent to which the self-instructional module on Rh-isoimmunization achieves the desired effect in improving the knowledge of staff nurses as evident from increase in knowledge scores.
KNOWLEDGE: In this study, it refers to the correct response from the respondents (staff nurses) regarding Rh-isoimmunization as elicited through self-administered questionnaire.
STAFF NURSE: In this study, it refers to the registered nurse either with Basic Nursing or Diploma/certificate programme in Nursing and Midwifery, working in maternity units of selected hospitals, Bangalore.
RH-ISOIMMUNIZATION: In this study, it refers to the development of antibodies (IgM and IgG) by the Rh-negative blood group pregnant women against the Rh-positive blood group fetus.
SELF INSTRUCTIONAL MODULE: In this study, it refers to a self instructional material prepared in English and Kannada regarding Rh-isoimmunization.
It consists of,
· Definition
· Incidence
· Pathophysiology
· Complications
· Prevention & management.
SELECTED VARIABLES: In this study, it refers to age, education, professional experience, experience in maternity ward, source of information and knowledge scores.
6.6 ASSUMPTIONS:
· Staff nurses will have some knowledge on Rh-isoimmunization.
· Staff nurses will be interested to upgrade their knowledge on Rh-isoimmunization.
6.7 DELIMITATIONS:
· The study is limited to staff nurses who are working in maternity units of selected hospitals, Bangalore.
· Staff nurses who are willing to participate in the study
7.0 MATERIALS AND METHODS:
7.1 SOURCE OF DATA
Data will be collected from staff nurses who are working in maternity units of selected hospitals, Bangalore.
7.2 METHODS OF DATA COLLECTION
7.2.1 RESERCH APPROACH: Quantitative research approach.
7.2.2 RESEARCH DESIGN: Pre-experimental one group pre and post-test design.
7.2.3 RESEARCH SETTING: Study will be conducted in maternity units of selected hospitals, Bangalore.
7.2.4 POPULATION: The population consists of staff nurses working in maternity units.
7.2.5 SAMPLE SIZE: The population consists of 40 staff nurses working in maternity units of selected hospitals, Bangalore.
7.2.6 SAMPLING TECHNIQUE: Purposive sampling technique.
7.2.7 SAMPLING CRITERIA
INCLUSION CRITERIA
· Staff nurses who are working in maternity units of selected hospitals.
EXCLUSION CRITERIA
· Staff nurses who are on leave during the period of study.
7.2.8 DATA COLLECTION TOOL
Self-administered structured questionnaire, which consists of,
Part-I: Deals with selected demographic variables.
Part-II: Deals with knowledge assessment on Rh-isoimmunization.
7.2.9 DATA ANALYSIS METHOD
Data analysis will be through descriptive and inferential statistics.
Descriptive statistics: Frequency, percentage, mean median, mode and standard deviation.
Inferential statistics: Parametric paired t’ test will be used to compare the pre-test and post-test knowledge scores.
7.3 DOES THE STUDY REQUIRE ANY OR OTHER INTERVENTIONS TO BE CONDUCTED ON PATIENTS, OR OTER HUMAN OR ANIMALS?
Yes, the study requires data collection through self-administered structured questionnaire on knowledge of staff nurses regarding Rh-isoimmunization.
7.4 HAS THE ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION?
Yes, Ethical clearance will be obtained from,
· The research committee of The Oxford College of Nursing, Bangalore.
· The authorities of selected hospitals, Bangalore.
· The informed consent from the candidates willing to participate in the study.
8. LISTS OF REFERENCES:
1. Klossner Jayne & Hatfield Nancy. Introductory Maternity & Pediatric Nursing. 1st edition. Philadelphia: Lippincott Williams & Wilkins Publications; 2006.
2. Adele Pillitteri, Maternal & Child health Nursing. 5th edition. Philadelphia: Lippincott Publications; 2007.
3. http://www.wrongdiagnosiscom/r/rhesus_isoimmunization/intro.htm
4. Matijevic R, Grgic O, Klobucar A, Miskovie B. A study on diagnosis and management of Rh-isoimmunization. Journal of Fetal Diagnosis and Therapy 2000 Sep-Oct; 20(5): 393-401.